Actualities in big segments replantation surgery

Functional Outcomes in Upper Limb Replantation-A Systematic Review

Functionality after upper limb replantation is a decisive factor when considering the success of the intervention. Therefore, its evaluation is fundamental. The aim of this article was to conduct a systematic review of upper limb functions after replantation or reimplantation, seeking to identify reported functional outcomes as well as the level and mechanism of injury. To achieve this objective, a literature search was conducted in PubMed, ScienceDirect, Cochrane and Web of Science. Studies from the last 10 years which included patients with upper limb replantation and reported their functional outcomes were included. Out of 523 articles, 12 studies (n = 607) were finally included. DASH and CISS were the most commonly used assessments to report functional outcomes. In conclusion, functional outcomes after replantation are assessed using widely varying scales; therefore, due to this methodological variability, it is difficult to compare functional success between studies and further studies on functionality are needed to provide new data.

Patient-reported significant disability after major traumatic upper extremity amputation

The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.

Management of Complex Forearm Injuries: Our Strategy of Reconstruction and Clinical Results

ABSTRACT

The management of complex forearm injuries is challenging, not only because of the anatomical complexity of the region but also because of the dramatic functional consequences of these injuries. Preservation of the upper limb and restoration of hand function are the focus of the surgical management of these injuries. Decision making will consider several parameters such as the type of injury, the patient, the moment of reconstruction, the debridement, and the options available for reconstruction.A multidisciplinary approach joining plastic surgeons and orthopedic surgeons in a team effort is essential to achieve the best outcomes. On the basis of their experience, the authors conclude that the keystone in complex forearm injuries management is represented by a careful assessment of the lesions, an aggressive and early debridement, the prevention of complications such as infection and compartment syndrome, and an "as early as possible" reconstruction.

Mangled upper extremity: Our strategy of reconstruction and clinical results

The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.

Replantation of amputation at the wrist: challenges of management in sub-Saharan Africa

Amputations of the upper limb, in particular, have a major impact on patients' lives, as loss of function can not only cause reduced autonomy in daily life but also hinder social interactions and capacity for work. Replantation at or proximal to the wrist, referred to as wrist-proximal replantation, remains a daunting challenge that presents the hand surgeon with an array of difficulties distinct from digital replantation.We present our experience with a successful replantation of a near-complete amputation at the non-dominant left wrist in a 25-year-old man managed in sub-Saharan Africa. Two years after replantation, the patient had a Disabilities of the Arm, Shoulder and Hand score of 40 and 2-point discrimination of 6 mm. We also discuss the peculiar challenges which have limited the development of replantation in the tropics. Environmental temperatures, manpower, expertise and technology are possible factors that limit this practice in the tropics.

Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review

Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation.

All hands on deck: Hand replantation versus transplantation

Objectives:

Our hands play a remarkable role in our activities of daily living and the make-up of our identities. In the United States, an estimated 41,000 individuals live with upper limb loss. Our expanding experience in limb transplantation—including operative techniques, rehabilitation, and expected outcomes—has often been based on our past experience with replantation. Here, we undertake a systematic review of replantation with transplantation in an attempt to better understand the determinants of outcome for each and to provide a summary of the data to this point.

Methods:

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted PubMed searches from 1964 to 2013 for articles in English. In total, 53 primary and secondary source articles were found to involve surgical repair (either replantation or transplantation) for complete amputations at the wrist and forearm levels. All were read and analyzed.

Results:

Hand replantations and transplantations were compared with respect to pre-operative considerations, surgical techniques, post-operative considerations and outcomes, including motor, sensation, cosmesis, patient satisfaction/quality of life, adverse events/side effects, financial costs, and overall function. While comparison of data is limited by heterogeneity, these data support our belief that good outcomes depend on patient expectations and commitment.

Conclusion:

When possible, hand replantation remains the primary option after acute amputation. However, when replantation fails or is not possible, hand transplantation appears to provide at least equal outcomes. Patient commitment, realistic expectations, and physician competence must coincide to achieve the best possible outcomes for both hand replantation and transplantation.

Long-Term Outcomes of Arm Replantation

BACKGROUND

Advances in microsurgery have improved the survival rate of arm replantation. However, the functional outcome of the replanted arms remains unpredictable. The authors performed a systematic review to evaluate the long-term outcome of arm replantation and the secondary reconstructive procedures after replantation.

METHODS

All available English literature in the PubMed, Embase, and CENTRAL databases was searched for articles reporting functional outcome of successful arm replantation with follow-up period more than 1 yr. Clinical data were extracted including study characteristics, patient demographic information, functional outcome, and the numbers, types, and timing of secondary surgery. Among these, factors identified to influence overall outcome were reviewed and analyzed.

RESULTS

Twenty-nine studies representing 79 arm replantations met the inclusion criteria. A total of 111 secondary procedures were recorded in 23 studies. The average number of secondary surgical procedures was 2.6 per patient. The most common procedures were nerve repair (23.4%), followed by functioning muscle transfer (19.8%), tendon transfer (17.1%), wound coverage (11.7%), contracture release (10.8%), bone repair (9.9%), arthrodesis (5.4%), and others (1.8%). Procedures involving wound coverage and nerve repair were mainly conducted in the early stage within 4 mos after replantation, whereas functioning muscle transfer, tendon transfer, and arthrodesis were mostly performed after 1 yr postoperatively. The satisfied (Chen I and II) functional outcome was achieved in 49.4% patients. The level of amputation and the type of injury have significant impact on final outcomes, whereas patients' age and timing of nerve repair do not. Patients with amputation at the distal third of the arms had a better outcome than those at the proximal and middle third of the arms (P < 0.05), and patients injured by sharp-cut recovered better than those by crush and avulsion (P < 0.05).

CONCLUSIONS

Optimal outcomes could be achieved in nearly half of patients with arm replantation, although multiple secondary surgical interventions and long periods of recovery are often required.

Replantation and revascularization of amputated upper limb appendages outcome and predicting the factors influencing the success rates of these procedures in a tertiary hospital: An 8-year retrospective, cross-sectional study

PURPOSE

Worldwide advances in microsurgery have made salvaging of amputated hand via replantation and revascularization common procedures. The present study examines the outcome of these procedures in a tertiary hospital in Malaysia.

METHODS

Patients with hand amputation who underwent replantation or revascularization from 2005 to 2012 were identified and reviewed for patient characteristics, amputation characteristics and survival rates. Successfully treated patients were interviewed to assess the functional outcome using Quick Disability of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Statistical analysis was performed to evaluate outcome and elicit predictive factors.

RESULTS

Fifty-five patients were enrolled: 37 (67.3%) underwent replantation and 18 (32.7%) underwent revascularization. The overall success rate of 78% ( n = 43) was within the range of previously reported data (61.6% to 96.0%). Ischaemic time <6 h provided significantly better survival rates ( p < 0.05). Functional outcomes were successfully assessed in 34 patients (79%), at a mean follow-up of 40 months (range 11-93 months). The overall Quick-DASH and MHQ scores were 42.82 ± 23.69 and 60.94 ± 12.82, respectively. No previous reports of functional outcome were available for comparison. Both Quick-DASH ( p = 0.001) and MHQ scores ( p < 0.001) were significantly higher for finger injuries, followed by thumb, wrist and palm injuries.

CONCLUSION

Ischaemic time and level of injury are important predictors of success rate of replantation and revascularization of amputated upper limb appendages.

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.

Complete major amputation of the upper extremity: Early results and initial treatment algorithm

BACKGROUND

Traumatic major amputations of the upper extremity are devastating injuries. These injuries have a profound impact on patient's quality of life and pose a burden on social economy. The aims of the current study were to report about the initial management of isolated traumatic major upper limb amputation from the time of admission to definitive soft tissue closure and to establish a distinct initial management algorithm.

METHODS

We recorded data concerning the initial management of the patient and the amputated body part in the emergency department (ED) (time from admission to the operation, Injury Severity Score [ISS], cold ischemia time from injury to ED, and total cold ischemia time). The duration, amount of surgical procedures, the time to definitive soft tissue coverage, and the choice of flap were part of the documentation. All intraoperative and postoperative complications were recorded.

RESULTS

All patients were successfully replanted (time from injury to ED, 59 ± 4 minutes; ISS16; time from admission to operating room 57 ± 10 minutes; total cold ischemia time 203 ± 20 minutes; total number of procedures 7.3 ± 2.5); definitive soft tissue coverage could be achieved 23 ± 14 days after injury. Two thromboembolic complications occurred, which could be treated by embolectomy during revision surgery, and we saw one early infection, which could be successfully managed by serial debridements in our series.

CONCLUSION

The management of complete major amputations of the upper extremity should be reserved for large trauma centers with enough resources concerning technical, structural, and personnel infrastructure to meet the demands of surgical reconstruction as well as the postoperative care. Following a distinct treatment algorithm is mandatory to increase the rate of successful major replantations, thus laying the foundation for promising secondary functional reconstructive efforts.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Replantation: current concepts and outcomes

Techniques to improve the chance of successful replantation of digits are well established. Indications and contraindications for replantation are generally agreed on, but they continue to evolve as excellent outcomes are achieved at centers with experience and expertise. Form and function can be restored with avulsion injuries and distal amputations, with good results and high patient satisfaction. Increased financial pressure to control the costs of health care and increased accountability for evidence-based outcomes may lead to the regionalization of replantation care and shared decision making in recommending replantation or revision amputation.

Cortical reorganization after macroreplantation at the upper extremity: a magnetoencephalographic study

With the development of microsurgical techniques, replantation has become a feasible alternative to stump treatment after the amputation of an extremity. It is known that amputation often induces phantom limb pain and cortical reorganization within the corresponding somatosensory areas. However, whether replantation reduces the risk of comparable persisting pain phenomena as well as reorganization of the primary somatosensory cortex is still widely unknown. Therefore, the present study aimed to investigate the potential development of persistent pain and cortical reorganization of the hand and lip areas within the sensory cortex by means of magnetoencephalographic dipole analyses after replantation of a traumatically amputated upper limb proximal to the radiocarpal joint. Cortical reorganization was investigated in 13 patients with limb replantation using air puff stimulation of the phalanges of both thumbs and both corners of the lower lip. Displacement of the centre of gravity of lip and thumb representations and increased cortical activity were found in the limb and face areas of the primary somatosensory cortex contralateral to the replanted arm when compared to the ipsilateral hemisphere. Thus, cortical reorganization in the primary somatosensory cortex also occurs after replantation of the upper extremity. Patients' reports of pain in the replanted body part were negatively correlated with the amount of cortical reorganization, i.e. the more pain the patients reported, the less reorganization of the subjects' hand representation within the primary somatosensory cortex was observed. Longitudinal studies in patients after macroreplantation are necessary to assess whether the observed reorganization in the primary somatosensory cortex is a result of changes within the representation of the replanted arm and/or neighbouring representations and to assess the relationship between the development of persistent pain and reorganization.

[Macro-replantation of the upper limb: long-terms results and quality of life]

OBJECTIVES

The authors suggest standardized questionnaires of quality of life to perform a long term evaluation of patients who underwent a replantation of the proximal upper limb.

METHODS

This retrospective study is about patients who underwent a replantation of the proximal upper limb between 1979 and 2011. The functional assessment was conducted using several tools including the 400 points test, the sensory tests, the Disabilities of the Arm, Shoulder and Hand questionnaire and the CHEN's classification. Some questionnaires, like the Medical Outcome Study Short Form-36 dealt with the physical and the psychological sides of the quality of life. Other questionnaires were more specific, like the Body Image Scale.

RESULTS

Sixteen patients were included. The survival rate of the replanted limb was 75%. The mean follow-up was 12.7 years. We noted 20% good results with a mean DASH score to 24.5%. The quality of life was similar to the general population in most of 50% of cases. Some patients had depressive symptoms or body image troubles.

CONCLUSIONS

In our eyes, the evaluation of quality of life seems essential for these patients. Survival rates, functional results, follow-up, professional activity, gender and body image troubles influence the quality of life. Besides, the physical side and the psychological side must change together to affect the overall results of the quality of life.

The epidemiology of amputation injuries in the Austrian helicopter emergency medical service: a retrospective, nationwide cohort study

PURPOSE

Data on the epidemiological characteristics of traumatic amputations in prehospital emergency care, especially in the context of air rescue, are scarce. Therefore, we aimed to describe the epidemiology of total and subtotal amputation injuries encountered by the OEAMTC helicopter emergency medical service (HEMS) in Austria, based on an almost nationwide sample.

METHODS

We retrospectively reviewed all HEMS rescue missions flown for amputation injuries in 2009. Only primary missions were analyzed.

RESULTS

In total, 149 out of 16,100 (0.9 %) primary HEMS rescue missions were for patients suffering from amputation injuries. Among these, HEMS physicians diagnosed 63.3 % (n = 94) total and 36.9 % (n = 55) subtotal amputations, with both groups showing a predominance of male victims (male:female ratios were 8:1 and 6:1, respectively).The highest rate occurred among adults between 45 and 64 years of age (35.6 %, n = 53). The most common causes were working with a circular saw (28.9 %, n = 43) and processing wood (16.8 %, n = 25). The majority of the cases included digital amputation injuries (77.2 %, n = 115) that were mainly related to the index finger (36.2 %, n = 54). One hundred forty patients (94.0 %) showed a total GCS of more than 12. Amputations were most prevalent in rural areas (84.6 %, n = 126) and between Thursday and Saturday (55.0 %, n = 82). The replantation rate after primary air transport was low (28 %).

CONCLUSIONS

In the HEMS, amputation injuries are infrequent and mostly not life-threatening. However, HEMS crews need to maintain their focus on providing sufficient and fast primary care while facilitating rapid transport to a specialized hospital. The knowledge of the epidemiological characteristics of amputation injuries encountered in the HEMS gained in this study may be useful for educational and operational purposes.

Long-term results of major upper extremity replantations

We analyzed the long-term functional outcome in patients with major upper extremity replantations. Two patients had amputations proximal to the elbow joint, two had elbow disarticulations and five patients had amputations at the forearm. The mean age was 24 and the mean follow-up time was 18 years. Six patients have undergone secondary operations. The mean grip strength was restored to 34% of the contralateral extremity. Protective sensation was restored in all patients. According to Chen's functional recovery scale, five patients had excellent, two had good, and two had fair results. Grip strength, two-point discrimination, ranges of motion and Chen's scale did not improve after 5 years. However, Semmes-Weinstein monofilament testing and cold intolerance continued to improve up to 10 and 12 years, respectively. Replantation of an upper extremity proximal to the wrist joint satisfactorily restored the upper extremity function.

Makroamputationsverletzungen im Bereich der oberen Extremität

Alle Amputationsverletzungen im Bereich der oberen Extremität distal des Radiokarpalgelenks werden als Mikroamputationsverletzungen bezeichnet.

Replantation of articular composite tissue masses severed from extremities

The techniques and outcomes of in situ replantation are discussed for managing 5 cases of articular composite tissue masses severed from an extremity (digit). All 5 cases treated with in situ replantation survived. Rehabilitation was performed after surgery. Follow-ups of 2-5 years showed good appearance, satisfactory functional and sensory recovery. In situ replantation is indicated for an articular composite tissue masses severed from an extremity (digit), if its structure is complete and a blood supply vessel in the mass is available for anastomosis. Replantation can achieve better outcomes than transfer or grafting of adjacent skin or osteocutaneous flaps, or transplantation of a metatarsophalangeal or interphalangeal joint.